A COMPARISON AND CONTRAST OF NURSING MODELS BY ROY AND NEUMAN
Robert W. Stein, III, RN, MSHA, CHE, LNC
Sister Callista Roy was born in 1939 in southern California. She first learned about the
adaptation concept in a psychology class while doing graduate work at the University of California, Los Angeles
in 1964. Roy1s Adaptation Model began when she was
challenged to develop a conceptual framework for nursing by Dorothy E. Johnson during a seminar at the university.
Sister Roy felt that this adaptation concept was an appropriate basis for a conceptual framework in nursing. Roy's
Adaptation Model was first put to use when the faculty at Mount Saint Mary1s in Los Angeles unaminously accepted it as the basis of the baccalureate nursing curriculum in 1968
(Gaibreath, 1985; Bonkoski, 1986).
Sister Roy first published her conceptual model in a 1970 Nursing
Outlook article titled, "Adaptation: A Conceptual Framework for Nursing".
She has authored and co-authored several books explaining and expanding her model. Among her writings are: Conceptual Models for
Nursing Practice (1974), Introduction to Nursing: An Adaptation Model (1976, 1984), and Theory Construction in Nursing: An Adaptation Model (1981).
In Roy's Adaptation Model (Roy, 1970, 1976), the person (man) is described as a biopsychosocial
being in constant interaction with a changing enviroment and having four modes of adaptation: physiologic, self
concept, role function, and interdependence. As internal and external enviromental changes (stimuli) occur, the
persons needs change resulting in deficits and excesses. To protect his physiologic, psychic, and social integrity
the person adapts using coping mechanisms to restore need satisfaction.
Roy describes the person as having a zone surrounding his variable level of adaptation. Stimuli
which fall within this zone will result in a positive response or adaptation. Stimuli which falls outside of this
zone will result in a negative response or maladaptation.
Two mechanisms of coping identified by Roy (1976) are the cognator and the regulator. The
cognator controls processes related to perception, learning, judgement, and emotion. The regulator functions primarily
through the use of the autonomic nervous system in making physiologic adjustments. In responding to the changing
enviroment, internal and I or external, the person uses the cognator and regulator mechanisms individually and
together to adapt, protecting his integrity. The resulting behavior is adaptive if a positive result occurs maintaining
the integrity of the person. A maladaptive behavior is a negative response that does not maintain the integrity
of the person.
The goal of nursing, in Roy's model is to promote positive adaptation in each of the four
adaptive modes of the person. Nursing is also concerned with illness prevention and health maintenance by widening
the person's zone of adaptation (Roy 1970, 1971, 1976).
The enviroment is described by Roy (1976) as being both internal and external in relation
to the person - system. It is in a state of constant change, and in a dynamic relationship with the person. Stimuli
from the enviroments affect the development and behavior of the person threatening his integrity.
Roy (1976) describes health as being a state of successful positive adaptation to stimuli
from the enviroment interfering with basic need
satisfaction and threatening to disrupt the system equilibrium. A healthy person is one whose
integrity has been protected as a result of his ability to adapt. Illness, therefore, is a state of threatened
integrity as a result of an inability to adapt or maladaptive responses to stimuli.
The nursing process, as defined in Roy's Adaptation Model consists of six steps: first level
assessment, second level assessment, problem identification, goal setting, intervention, and evaluation (Roy, 1976).
First level assessment - the assessment of client behaviors - is the evaluation of the persons
behavior in each of the four adaptive modes:
physiologic, self concept, role function, and interdependence. The nurse then selects areas
of concern, either maladaptive behaviors requiring reinforcement. These areas of concern are then taken into second
level assessment (Roy, 1976).
In second level assessment - the assessment of influencing factors -the nurse takes the behaviors
of concern and further evaluates them determining the focal, contextual, and residual stimuli contributing to them.
The focal stimuli is the extent or degree of change immediately confronting the person. The contextual stimuli
are all other stimuli affecting the person presently. Residual stimuli consists of the beliefs, attitudes, and
experiences which color his reactions to the focal stimuli. Assessment of the focal, contextual, and residual stimuli
will allow for an individualized nursing diagnosis, behavioral goals, and nursing actions for the person (Roy,
1976).
Problem identification or nursing diagnosis is a prioritized list of short summary statements
of the persons problems evaluated in the second level assessment. As previously stated, the nursing diagnosis is
related
to the four adaptaive modes. Roy offers her own typology of nursing diagnosis, however, she
feels that using statements of behavior and influencing factors may be more productive until nursing has a standardized
nomenclature (Roy, 1976).
Goal setting is a cooperative effort between the nurse and the person whenever possible.
Generally, the nursing goal is to change maladaptive behaviors, reinforce adaptive behaviors, and to enhance the
person's coping abilities. Nursing goals should always be stated in terms of behavioral outcomes for the person
(Roy, 1976).
Intervention can take place by two different approaches or both approaches combined. In the
first approach, the nurse manipulates the focal stimuli to allow for a positive adaptive response. The second approach
is to widen the person's zone of adaptation so that the stimuli falls within the person's ability to adapt positively.
The consequences of each manipulation are evaluated and the one with the highest probability of a positive response
and lowest probability of an undesired outcome are selected (Roy, 1970,1976).
Evaluation is the final step in the nursing process. The effectiveness of the nursing action
is determined by the assessment of the person's outcome behaviors. If the outcome behaviors are the same as the
stated goals, then the intervention has been successful. If the outcome behaviors are still maladaptive, further
evaluation of the nursing action needs to take place for consideration of a different approach. Once adaptive behaviors
are developed, the nursing process is started over to evaluate any new or on-going problems. As a result, the nursing
process is cyclical in nature (Roy, 1976).
Testable theories can he,and have, generated from the Adaptation Model. There are many testable
aspects to the model. Roy and others have encouraged testing to validate the model and to generate nursing knowledge
as a science (Wagner, 1976; Hammond, Roberts, & Silva, 1983).
Hammond, Roberts, & Silva (1983), to further nursing science tested two groups of nurses,
one using first and second level assessment and the other using first assessment alone. Their results demonstrated
no significant difference in reaching accurate nursing diagnosis between the two groups. The importance of their
study, they state, is not in their results, but in demonstrating that nursing models can provide researchable questions,
be tested, and then returned to nursing as science,
In summary, Roy (1970, 1971, 1976) described a model for nursing based on the concept of
adaptation. There are five major concepts of nursing explicated in her model: the person, the goal of nursing,
nursing activities, health, and the enviroment. These concepts are interrelated to the concept of adaptation. The
person is viewed as having four different modes of adaptation: physiologic, self concept, role function, and interdependence
modes. Roy's model is concerned with the internal and external enviromental stimuli affecting the development and
behavior of the person. The level of adaptation of the person is assessed and ways to remove the stimuli, to enhance,
or to maintain adaptation are explored by the person and the nurse. Roy's model is written referring to the person
as an individual client, however, her model can easily be applied to family groups or communities as well.
Betty Neuman was born in 1924 in Ohio. She is a 1947 diploma school nursing graduate from
Peoples Hospital School of Nursing in Akron, Ohio. She has completed her M.S. in Mental Health, Public Health Consultation
in 1966 from the University of California, Los Angeles. In 1985 she was working toward her doctoral degree in nursing.
She developed her nursing model while teaching community mental health at the University of California, Los Angeles
during the late 1960's. Her graduate students felt a need to have an overview of nursing prior to learning specifics.
Neuman developed her model to meet this curricular need. Her conceptual model is based heavily on the general systems
theory of von Bertalanffy. Other theorists influencing Neuman include the wholism philosophies of de Chardin, Cornu,
and Gesalt; as well as stress response theory by Selye, and prevention levels by Caplan (Cross, 1985).
Betty Neuman first published her Health Care Systems Model in a 1972 Nursing Research article titled, "A Model
for Teaching Total Person Approach to Patient Problems". The model was clarified and refined in Neuman's contribution
to the book Conceptual Models
for Nursing Practice (1974, edited by J.P. Riehi and C. Roy. Her most recent work
is The Nevr~an Systems Model: Application
to Nurs!Lgn~Education and
Practice (1982) which further refines her model and
provides examples of how it may be applied to practice, education, and administration (Cross, 1985).
Man is described by Neuman (1972, 1982) as having a basic core consisting of normal parameters
of vital signs, genetic structure, ego structure, organ strengths and weaknesses. This core is then protected by
a flexible line of defense, a normal line of defense, and lines of resistance. The flexible line of defense is
a varible shock absorber serving as a buffer to the normal line of defense. The normal line of defense consists
of a normal range of responses developed over time that serve to ke&p man in a state of equilibrium. Lines
of resistance are internal factors which protect man's survival in face of stressors which have penetrated his
flexible and normal lines of defense. Individual varibles of man include: physiological, psychological, sociocultural,
and developmental. Stressors may affect more than one varible at a time; and more than one stressor can affect
man at a time.
Neuman (1982) views nursing as being the leader of the health care team by virtue of it's
broad scope. It takes a wholistic approach, being concerned with man's total being. The goal of nursing is to assist
man in retaining, attaining, and maintaining an optimal level of weliness. This is accomplished through nursing
interventions focused on controlling stressors from the enviroment and the subsequent stress reactions. Neuman
uses the term reconstitution to describe the returning of the man - system to a stable state. This stable state
will be the optimal level of wellness and may be at a more or a less well state than previously.
The enviroment consists of everything that comes in contact with man. The enviroment may
be internal or external in relation to the man - system. The enviroment is conceptualized as being in a dynamic
relationship with man. It is constantly changing, affecting and being affected by man. Stressors are disrupting
forces to man originating in the enviroment. They may affect the intrapersonal, interpersonal, and I or the extrapersonal
factors of man. Stressors create disorganization and energy loss for the individual. Stressors may be considered
noxious or benefical depending on the outcome (Neuman, 1982).
Health is defined by Neuman in terms of a wellness to illness to wellness continuum. Wellness
is a negentrophic state where all man's basic needs are met. Illness is an entrophic state with some basic needs
not being met. Neuman includes the concept of optimal wellness in her model. The inclusion of this concept allows
for individual consideration of each unique person. Health, therefore, is the optimal state possible for each individual
at a given time (Neuman, 1982).
The nursing process, according to Neuman (1982), is a three stage procedure consisting of
a nursing diagnosis, nursing goals, and nursing outcomes. Each stage in the process contain several steps.
The nursing diagnosis is formulated using Neuman's Assessment I Intervention Tool. "Based
on aquisition of appropriate data base, the diagnosis identifies, assesses, classifies, and evaluates the dynamic
interaction of the bio - psycho - sociocultural - developmental varibles. Variances from wellness (needs / problems)
are determined by correlations~n~straints ~ through the synthesis of theory and data base. Broad hypothetical interventions are determined; i.e., maintain flexible line
of defense" (Cross, 1985, p.17).
In the second stage, nursing goals are formulated with the assistance of the client whenever
possible. Intervention strategies are developed with the general goal of nursing being system stability in retainment,
attainment, and maintainment of an optimal level of wellness. (Neuman, 1982).
The final stage according to Neuman, (1982) is nursing outcomes. In this stage nursing implements
the intervention strategies developed. The intervention may take the form of primary prevention - to retain system
stability, secondary prevention - to attain system stability, and I or tertiary prevention - to maintain system
stability. Evaluation of client outcomes confirms prescriptive change, or serves as a basis for reformulation of
nursing goals (Neuman, 1982).
Neuman (1982) suggests further research and development utilizing the Health Care Systems
Model. ~~areas of research and development recommended are to establish the impact of changing enviromental forces
upon nursing, development of a common nursing language leading to a nursing grand theory with systems concept as
a basis, and developing a closer approximation of nursing phenomena by increasing order and understanding (Neuman,
1982).
The first use of the Health Care Systems Model in research and development was described
by B.M. Neuman and R.J. Young in th~97) Nursing Research
article titled "A Model for Teaching Total Person Approach to Patient Problems". The University of California
School of Nursing required their graduate students to take one of four specific nursing management courses. The
students felt they would benefit from a course which increased the breadth of nursing as opposed to the depth.
A committee was established and a course based on the Neuman Health Care Systems Model was developed.
Participation in the experimental program was optional. The course was designed as two, two
hour lectures weekly for the length of the semester. The course was taught by two faculty members in their areas
of expertise. Each lecturer spoke on a universal stressor, considering the physiological, psychological, sociocultural,
and developmental varibles. A coordinator served to provide guidelines for the faculty. The main objectives of
the pilot program was to provide an introduction to theory and knowledge based on the four va~s, apply relevant
theory to practice, provide a framework to operationalize the nursing process, and to stimulate further inquiry
and nursing research (Neuman & Young, 1972).
Evaluation of the pilot progam was done by interviews with the students by faculty not participating
in the lectures. Following the first trial, the evaluation was favorable indicating they had met their stated goals
and that the program should be continued. A second trial was done with similar results but recommendation to make
minor changes in addition. The refined course is now a regular course offe~ing at the University of California,
Los Angeles School of Nursing (Neuman & Young, 1972).
Roy and Neuman are very much alike. They are similarly educated, both being at the University
of California, Los Angeles in the mid - 1960's. In developing their models they both borrowed from other disciplines,
i.e., general systems theory by von Bertalanffy and stress reaction theory by Selye, etc. They both believe that
nursing is the ring leader of the health care team. They each state that their models may be applied to the individual
client, a family group, or the community itself. Roy and Neuman feel that there is a need for a standardized nomenclature
in nursing and have encouraged research and development of their models. Both theorists have had their models initiated
in nursing curriculums, Roy's at Mount Saint Mary's, and Neuman's at the University of California. Each model has
been tested and researched.
Roy and Neuman often use different terms, but share similar definitions of the four major
concepts in nursing. Both consider internal and external enviroments that are constantly changing, and in a dynamic
relationship with man. Health is a state of system stability in which man's needs are met. Man is viewed wholistically,
considering his bio-psycho-social being. Nursing is a cooperative effort between man and the nurse. The goal of
nursing is to assist man in reaching his optimal level of weilness.
The nursing process by Roy and Neuman are broadly similar, using different terms, but essentially
alike. Both contain assessments of man's response to stressors and the underlying varibles contributing to his
response.
Problems are identifLed, categorized, and interventions formulated to meet established goals.
Following the implementation of the intervention an evaluation of the outcome takes place to validate the nursing
process, or serve as a data base for reassessment.
Neuman and Roy are different in a few ways. First, Neuman is 15 years older than Roy, yet
Roy developed her model about four years before Neuman did hers. Roy developed her model for nursing, while Neuman
felt that her model should be used by all health care workers. Roy coined some of her own terminology, whereas,
Neuman borrowed terms from other disciplines.
The concepts of stress reaction and the general systems theory are congruent with societies
needs as well as those of the nursing profession. The cost of health care today and the growing older poplyation,
which generally require more health care services than others, is so great that there is a need for providers and
recipients of health care to take responsibility to limit costs. The concepts of stress reaction theory and the
general systems theory are simple enough for everyone to understand and use. They allow documentation of needs
and development of goals without becoming burdensome. With stated goals, and science to support us, nursing can
justify it's actions and expense to clients, third party payors, institutions, and the government. This justification
will help to limit costs by focusing our care on that which is truely necessary, promoting nursing as a profession.
In summary, there are many more likenesses than contrasts between Roy, Neuman, and their
models for nursing practice. Both theorists use similar definitions of the four major concepts in nursing. Each
has expanded on the traditional nursing process, but on close examination, it's really the same nursing process
with a wholistic perspective. Many of these similarities may be due to their similar educational backgrounds. Roy's
Adaptation Model and Neuman's Health Care Systems Model are currently congruent with the needs of society and of
the nursing profession.
REFERENCES
- Bonkoski, J.I. (1986). Sister Callista Roy's Adaptation Model. Unpublished manuscript, beorgetown University, School of Nursing, Graduate studies, Washington,
D.C.
- Cross, J.R. (1985). Betty Neuman. In J.B. George (Ed.) Nursing Theories: The Base for Professional Nursing 2nd.. NewJersey: Prentice - Hall. ~ f
- Hammond, H., Roberts, M.P., & Silva, M.C. (1983). The Effect of Roy's First and Second
Level Assessment on Nurses's Determination of Accurate Nursing Diagnosis. Virginia Nurse, 2, 14 -
- Gaibreath, J.G. (1985). Sister Callista Roy. In J.B. George (Ed.) NursingTheories:	The
Base for Professional
Nursing Practice, 2nd. (pp. 301) - 318).
- Neuman, B.M. &R.J.Young (1972). A Model for Teaching Total Person Approach to Patient
Problems. Nursing Research, 21, 264 - 271.
- Neuman, B.M. (1982). The Neum~tems Model: Application to Nursing
Education and Practice. New York: Appleton - Century - Crofts.
- Roy, C. (1970). Adaptation: A Conceptual Framework for Nursing. Nursing
Outlook, 1~ (3), 42 - 45.
- Roy, C. (1971). Adaptation: A Basis for Nursing Practice. Nursing
Outlook, 19 (4), 254 -
257.
- Roy, C. (1976). Introduction to
Nursing: An'Adaptation Model. New Jersey: Prentice -
Hall.
- Whall, A.L. ( ). The Betty Neuman Health Care Systems Model. In Conceptual
Models of Nursing.
- Wagner, P. (1976). The Roy Adaptation Model: Testing the Adaptation Model in Practice. Nursing Outlook,
24, (11), 682 - 685.
